Page 1530 - Saunders Comprehensive Review For NCLEX-RN

4. Nonfat milk
5. Fried chicken

6. Scrambled eggs

536. A client has undergone esophagogastroduodenoscopy. The nurse should
place highest priority on which item as part of the client’s care plan?
1. Monitoring the temperature
2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex
537. The nurse has taught the client about an upcoming endoscopic retrograde
cholangiopancreatography (ERCP) procedure. The nurse determines that the
client needs further information if the client makes which statement?
1. “I know I must sign the consent form.”
2. “I hope the throat spray keeps me from gagging.”
3. “I’m glad I don’t have to lie still for this procedure.”
4. “I’m glad some intravenous medication will be given to relax me.”
538. The primary health care provider has determined that a client has contracted
hepatitis A based on flu-like symptoms and jaundice. Which statement made
by the client supports this medical diagnosis?
1. “I have had unprotected sex with multiple partners.”
2. “I ate shellfish about 2 weeks ago at a local restaurant.”
3. “I was an intravenous drug abuser in the past and shared
needles.”
4. “I had a blood transfusion 30 years ago after major abdominal
surgery.”
539. The nurse is assessing a client 24 hours following a cholecystectomy. The
nurse notes that the T-tube has drained 750 mL of green-brown drainage
since the surgery. Which nursing intervention is most appropriate?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the primary health care provider.
540. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which
assessment finding would most likely indicate perforation of the ulcer?
1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, board-like abdomen
541. The nurse is caring for a client following a gastrojejunostomy (Billroth II
procedure). Which postoperative prescription should the nurse question and
verify?
1. Leg exercises
2. Early ambulation
3. Irrigating the nasogastric tube
4. Coughing and deep-breathing exercises
542. The nurse is providing discharge instructions to a client following

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